Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a really bad outcome. That’s what happened to Lewis Blackman, as we saw in Tears to Transparency.

Next, the group got a different domino pattern and could have a briefing before the start of the game.  Also, I noticed that in our group, the person playing the physician gave more precise instructions and repeated them for more clarity.  So there was learning and improvement between the first and second rounds. This time, the person role-playing the nurse arranged the dominoes correctly.

I took away from this experience lessons on how I need to be precise in communicating, whether in the classroom, at work or at home.

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Reflections on Telluride East: Day Three by Lynne Karanfil, RN, CIC

Loved the discussions on high reliability. Healthcare can learn a lot of lessons from the US Navy as Dave Mayer pointed out. If you want to see our Navy in action, you only need to go to Facebook. Each vessel has a Facebook page that they post how they do some of their operations. Below is a link to the carrier USS John Stennis. They also share their thoughts on leadership as well. We don’t have to go to far on seeing how to do things safer! Sometimes the answers are in our own backyard.

https://www.facebook.com/#!/photo.php?v=10152313797947334&set=vb.110454772346710&type=2&theater

Telluride Day 2 Reflection by Yimei Huang Pharm.D Candidate 2015

The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?

A fun thing for today was Teeter Totter Game. This was my first time playing the game personally, and I really enjoyed the moments when our team worked so closely for a common end. At those moments, I felt so supported, accompanied and comfortable to come up with and share ideas with my teammates to work out a better plan. We were successful, but it was not the outcome itself that is dearest to me. It was the process before, during and after that 10 minutes. I would say every team has achieved this process and experienced the similar feeling as ours.

The most emotional and thought-provoking activity of the day was discussing the film “The Story of Michael Skolnik”. As I said in the meeting, I am curious to know what measures have been taken in the past ten years to improve. What has been done to cut off the unnecessary incentives that make surgeons desire to do procedures and even induce patients to agree? What has been done to guarantee a second-point checker for the clinical decision even when patients themselves do not have the second resource accessible? What has been done to ensure that risks are thoroughly informed rather than partially? How well is the fact of surgeon’s expertise and experience honestly communicated to patients? How often does it still exist that assuring patient of one senior surgeon to win their signature but actually carrying out the procedure by his/her student? Maybe taping or video taping the informed consent conversation would help? Maybe a consultant meeting with everyone involved in the case would help? Maybe a written form of patient’s teach-back document files to the supervision level would help? Where are we getting right now?

The day ended with a recap on Dr. Cliff’s Listen to the Rhythm. What an inspiring day!

Day One: Telluride East Reflections

By Linda Hunter, RN, PhD Student

I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have lost due to error – every “error” has a face and all have a story that continues. Let’s continue to work together and realize how vital it is that we all have and use this knowledge and then share and spread the patient safety knowledge with our peers back home.

By Lynne Karanfil RN

What makes a train? Not just the engine or cars but the coupling device that hooks it together….Professor Cliff Hughes indicated….we need to be a team to make change happen…brilliant!

And then Garrett, 2nd year medical student asked me why don’t all medical school curricula have a course on patient safety like Telluride East? Spot on Garrett! All healthcare providers should have this basic training! Day one at Telluride East was phenomenal! I always learn something new from listening to Lewis’s story and how to engage the healthcare community to become better change agents. Day two..bring it on!

By Rose Ngishu

From tears to transparency is a very powerful story that captures many of the barriers to patient safety in our hospitals. It is more than an irony of ironies. As Helen Haskell pointed out, it is sad that “if Louis had been anywhere other than the hospital, he would still be alive.” Until every patient is safe all the time in the hospital, we are challenged to keep speaking up. And when that goal is achieved, we have yet to keep speaking up on matters of safety.

Telluride “East” Kicks Off at Georgetown University in Washington DC

This week we transport the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps to the heart of the nation’s capitol — Washington DC. Dave Mayer MD and Tim McDonald MD/JD along with faculty Paul Levy, Rosemary Gibson, Helen Haskell, Cliff Hughes, Kathy Pischke-Winn, Joe Halbach, Gwen Sherwood and more will educate the young of healthcare, sharing communication skills, patient stories and negotiation training in the spirit of keeping patients safe. The Telluride alumni numbers continue to grow, building that critical mass of voices who can share the wisdom of open, honest communication and transparency throughout medicine.

Student reflections on this year’s camps, as well as last year, are found throughout the Transparent Health blog, on Educate the Young and on faculty member Paul Levy’s blog, Not Running A Hospital. Look for additional reflections from this week’s class soon to come, and follow us on Twitter via #TPSER9. The goals of this week’s program follow.

TRANSFORMING MINDSETS III

“The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency”

Patient Safety Student and Resident Summer Camp learning objectives:

By the end of the Patient Safety Summer Camp, students will be able to:

1.)   Describe in-depth at least three reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement and reducing risk in healthcare.

2.)   Recognize and apply basic communication skills to improve effective communication among members of the healthcare team.

3.)   Utilize effective tools and strategies to lead change specific to reducing patient harm.

4.)   Implement, lead and successfully complete a Safety/QI project at their institution over the next twelve months.

Telluride Reflections by Quyen Nguyen

6/17/2013

One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.

Today I also learned about the concept of anchoring. Anchoring is a practice in which a person’s perspective is biased by the first information given. The tendency of anchoring increases significantly when one becomes tired, fatigued or distracted by any other human factors. The heartbreaking tragedy we have seen in Carole’s and Helen’s stories stems from anchoring bias. As a caregiver, we have to be mindful and avoid bias when dealing with patients. However, after several talks with several medical students and nursing students, I learned that many residents may have to work up to 80 hours/week on average and many times they have to work more than 8 hours in a shift (please correct me if I am wrong). I wonder whether it is possible for one to maintain a clear mind with an objective perspective under these working conditions. Should there be a change to reduce such long working hours in residency programs?

6/19/2013
Yesterday, I went shopping and talked to a cashier in a souvenir shop in downtown Telluride. After I asked her whether she offered any discount for Telluride scientists, we started having an interesting conversation. On being asked what I was there for, I shared with her that I was in a 4-day summer school with medical students, nursing students, and pharmacy students to learn more about patient safety and how to improve healthcare quality. She then told me that since we were learning about patient safety, we should make sure that nursing school teaches nurses how to take blood sample of a patient without pricking her patient five or six times. She suggested that doctors should invent some kind of X-ray imaging on a patient’s arm so that they can test the blood without pricking a patient. We both laughed and I said, “Yeah, why not?” Such an invention may be possible in the future and it would increase the ability to deliver high quality patient care. I thought this is an interesting anecdote of those outside the medical profession on how they perceive those inside.

#TPSER9 – Telluride Student Summer Camp Reflections on USA Today Article and more

By Aaron Cantor, BS, ENS, MC, USNR, MSII Pennsylvania State College of Medicine

On my way back home from Telluride, I happened to pick up a copy of USA Today from 20 June.  I was pleasantly surprised to see that the front page featured a special report, “When Health Care Makes You Sick: Under the knife for nothing.”

Although the article highlights medical errors, interviews Lucian Leape and Rosemary Gibson, and even mentions the story of Michael Skolnik, its tone perpetuates acceptance of medical errors and withholding of valuable information:  there is a way to know the total number of cases in which people got surgery that wasn’t needed if honest disclosure is practiced; hospitals are required to report infection and surgical errors to a governing body, but reporting to the patient and family (those who are most affected) may not be required.  The article goes on to describe several other instances in which reports of complications are too difficult to obtain, doctors are pressured into performing more surgeries to generate more revenue in a fee-for-service model, or people are rushed into procedures without being recommended to obtain a second opinion.  The article also places most of the burden of preventing unnecessary surgeries on the patient, promotes a doctor-patient antagonism, and erodes trust in the healthcare system.  Stories and methods of overcoming these barriers to safe and effective healthcare are not described, which maintains a negative attitude against healthcare and sensationalizes only poor outcomes.

Fortunately, an important comment from Gibson is included in the article but it is not further explained.  She states that “the system, in my opinion, doesn’t want to know about the problem [of unnecessary surgeries].”  As we discussed during our meetings, most of the healthcare system is perfectly designed to the results it gets…so let’s focus on how the system promotes, say, unnecessary surgeries and work towards changing that system.  The past few days in Telluride with our awesome group allowed me to meet agents of this change and learn about techniques for both enacting system changes and promoting awareness of system faults.  For instance, Tim explained the new Clinical Learning Environment Review (CLER) Program, which assesses the graduate medical education learning environment and focuses on patient safety and quality improvement among six focus areas.  This is great ammo with which to convince administrators to more carefully consider the culture and systems in place at your institution and support a project you are planning that aims to reduce errors.

But as Garrett and Suresh describe in their most recent posts on 21 and 23 June, respectively, these types of changes and patient safety training often receive too little emphasis from top administrators all the way down to residents and senior medical students.  I think at least two activities can help encourage students to support system changes towards greater transparency.  One method is experiential learning; if students personally experience outcomes of a common procedure or medication, then they are more likely to understand the patient experience and be better equipped to describe, say, what to expect during an MRI or nasogastric tube insertion and maintenance.  Understanding the patient experience translates to greater honesty and a higher degree of care and mutual trust.  Reminding students to pause and think about the patient as if that person were a family member may also influence students to act more cautiously and disclose all relevant information.

Another activity is following consenting patients with chronic conditions during their normal activities of daily living.  This affords students the opportunity to experience how illness affects people and their families outside of the medical environment and further enhances empathy, all of which encourage greater transparency in healthcare.  An example of this activity is below.

A description of The Patient Project can be found here. Videos can be found here.

The caliber of all Telluriders was phenomenal as well as inspirational, since each of us will have to overcome an ingrained healthcare culture at some point in our careers if not done so already.  I look forward to learning about the results from ongoing and developing projects as well as the sharing of ideas that emerge from our meeting.

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